RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00747
BRANCH OF SERVICE:  Army	BOARD DATE:  20150127
SEPARATION DATE:  20070402

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-6 (M1A1 Armor Crewman) medically separated for chronic back, left shoulder, and bilateral knee pain.  These conditions could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards.  He was issued a permanent U3L3 profile and referred for a Medical Evaluation Board (MEB).  The back condition, characterized as “degenerative arthritis of lumbosacral spine with facet arthropathy and spondylosis of L5 resulting in low back pain,” along with “acromioclavicular degenerative joint disease” and “patellofemoral syndrome,” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “chronic low back pain with atraumatic onset,” as unfitting, rated 20%, referencing the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The “chronic left shoulder pain” and “chronic bilateral knee pain with atraumatic onset,” were determined to be unfitting and rated 0% and 0% respectively, with the bilateral knee condition rated with application of the US Army Physical Disability Agency (USAPDA) pain policy.  The CI made no appeals and was medically separated.

CI CONTENTION:  “The following issues with my spine injury where not included but are service-connected are PTSD, tinnitus in ears, left shoulder torn, and R-L Knee Damage.”  [sic]

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2).  It is limited to those conditions determined by the PEB to be unfitting for continued military service and when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military/Naval Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation.  The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation. 

RATING COMPARISON:

Service IPEB – Dated 20070226	VA - 11 Mos. Post Separation	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5242	20%	Degenerative Arthritis of L-Spine	5299-5242	10%	20080318	
Chronic Left Shoulder Pain	5003	0%	DJD, Left Acromioclavicular Jt	5003-5021	0%	20080318	
Chronic Bilat Knee Pain	5099-5003	0%	Patellofemoral Syndrome, Bilat	5299-5261	0%	20080318	
Other x 0 (Not in Scope)	Other x 2	
Combined:  20%	Combined:  20%	
Derived from VA Rating Decision (VARD) dated 20080522

ANALYSIS SUMMARY:

Chronic Low Back Pain.  According to service treatment records and the MEB narrative summary (NARSUM), the CI had chronic intermittent low back pain (LBP) since 2003.  It was treated with manipulation, activity modification, physical therapy (PT), and medication.  The CI continued to perform duties and passed the Army Physical Fitness Test with high scores in April 2005 and January 2006.  X-rays of the lumbosacral spine in March 2006 noted degenerative changes at L5.  A nuclear bone scan in April 2006 was normal demonstrating no abnormal activity in the lumbosacral spine.  The CI passed the physical fitness test on 11 August 2006 again with high scores.  In November and December of 2006, the CI presented to clinic the back pain interfered with his ability to perform strenuous military duties or deploy.  The pain did not go below the buttocks, there was some loss of feeling in the right foot, and there was no reported incontinence.  At the MEB NARSUM examination on 25 January 2007 (3 months prior to separation), the spine was straight and non-tender.  The CI had diminished sensation to light touch in the right foot, normal strength of the lower extremities, and normal reflexes.  Lumbosacral flexion was 45 degrees (normal 90 degrees) and combined ROM was 185 degrees (normal 240 degrees).  At the VA Compensation and Pension (C&P) general exam performed on 18 March 2008 (11 months after separation), the CI had normal strength, sensation, and reflexes of the upper and lower extremities.  At the VA C&P spine exam performed a week later, the CI noted muscle spasms; no leg or foot weakness; lower back pain that was irregular, aching, moderate, lasted for hours, occurred weekly to monthly, and did not radiate.  On examination, there was no spasm, guarding, or tenderness; normal gait; normal spinal curvature; and normal upper and lower muscle strength and sensation.  Thoracolumbar spine flexion was 90 degrees (normal) and painless with repetitions, and combined ROM was 230 degrees (normal 240 degrees).

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the LBP with code 5242 (degenerative arthritis of the spine) at 20%, noting that the forward flexion was mechanically limited to 45 degrees.  The VA rated the condition analogously to code 5242 at 10%, citing the range-of-motion (ROM) measurements done at the C&P examination.  The limitation of motion at the MEB examination supported the 20% rating adjudicated by the PEB.  There was no intervertebral disc syndrome or incapacitating episodes requiring bed rest prescribed by a physician to support a minimum rating using the alternate formula for intervertebral disc syndrome.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the LBP condition.

Chronic Left (non-dominant) Shoulder Pain.  The MEB NARSUM noted that the CI had onset of shoulder pain while heavy lifting in Iraq in 2004.  Treatment included activity modification, PT, and medications.  Magnetic resonance imaging on 15 April 2005, was “suggestive of acromioclavicular joint arthropathy” (disease) but without significant degenerative changes noted in the acromioclavicular (AC) joint.  The AC is between the clavicle (collar bone) and the acromion (part of the scapula bone, at the highest point of the shoulder).  
At the time of the Army Physical Fitness Test on 15 April 2005, the CI performed 75 push-ups (earning a maximum score of 100 points).  There are no further clinic entries for care of shoulder pain until 14 December 2006 when the CI reported left shoulder pain interfered with his ability to perform strenuous military duties or deploy.  The MEB NARSUM examination on 25 January 2007, demonstrated “swelling and tenderness about the left acromioclavicular joint with cross over pain” (crossing the arm, at shoulder level, straight over to the right side; tests for AC joint problems).  The ROM was “full,” and no other abnormalities of the shoulder were noted.  An activity limiting profile was recommended.  Prior to this time, there was no activity limiting profiles for shoulder pain in evidence in the file.  The C&P examination on 18 March 2008, 11 months after separation, demonstrated no motor loss, normal reflexes, and normal sensation of the upper extremities.  Flexion and abduction were 180 degrees (normal) and painless with repetitions.  There was no crepitus or muscle atrophy.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the condition with code 5003 at 0%, citing the full ROM and good stability.  The VA rated the condition at with code 5201 (Arm, limitation of motion of) at 0%, citing normal ROM; no objective evidence of painful motion, swelling, or muscle spasm; and no evidence of arthritis on X-rays.  Both the PEB and proximate post-separation VA exams demonstrated painless and full ROM, which warrant a 0% rating by code 5003 or 5201.  The Board did not see a pathway to a higher rating by using any other applicable orthopedic code.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the left shoulder condition.

Chronic Bilateral Knee Pain.  According to the MEB NARSUM the CI reported a gradual onset of bilateral knee pain since 2002, associated with training and running.  The CI passed the two mile run of the physical fitness test in April 2005, January 2006 and August 2006 with good times and high scores (11 August 2006, 13 minutes, 42 seconds scoring 96 points with a maximum of 100 points).  On 5 September 2006, the CI presented to the clinic with complaint of knee pain for 2 weeks with running and walking.  An elastic knee sleeve (to support the knee cap) was prescribed. At the time of the 14 December 2006 overseas physical examination, the CI reported various musculoskeletal complaints including leg pain (without specific mention of the knees).  At the time of the MEB NARSUM examination on 25 January 2007, the CI reported anterior knee pain with popping.  There was no history of locking or giving way.  Treatment included an elastic knee sleeve (to support the knee cap), medications, and foot inserts without resolution.  The CI told the MEB examiner that the knee pains interfered with his ability to perform normal military duties.  An activity limiting profile was recommended.  Prior to this time, there was no activity limiting profiles for knee pain in evidence in the file.  On examination there was tenderness of the patella (knee cap) with crepitus (grating).  There was no swelling or effusion (fluid in the knee).  The ROM of both knees was “normal” and there was no ligamentous instability.  At the VA C&P examination on 18 March 2008, (11 months after separation), the CI complained of pain and stiffness in both knees, with no locking or joint swelling (effusion).  The examiner wrote, “Does the condition affect motion of one or more joints:  No.”  The CI had normal gait, no tenderness or swelling, no muscle atrophy, and no joint laxity.  The ROM was 0 degrees to 140 degrees (normal), and was painless with repetitions.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the condition with analogous code 5003 at 0%, citing the full ROM, good stability, and slight/occasional pain.  The VA rated each knee analogously to code 5260 (Leg, limitation of flexion of) at 0%, citing the full ROM and lack of evidence of painful motion, swelling, muscle spasm, subluxation, or lateral instability.  The Board noted that the full ROM and absence of painful motion warranted a rating of 0% under both examinations.  

There was no VASRD §4.71a route to a rating higher than 0% under any applicable code, and no grounds for additional rating for instability.  
After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the bilateral knee condition.

BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  As discussed above, PEB reliance on the USAPDA pain policy for rating the bilateral knee pain was operant in this case and the condition was adjudicated independently of that policy by the Board.  In the matter of the chronic LBP condition, and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the chronic left shoulder pain condition, and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the chronic bilateral knee pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, undated, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

		

SAMR-RB									

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXX, AR20150008692 (PD201400747)

I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual.  Under the authority of Title 10, United States Code, section 1554a,   I accept the Board’s recommendation and hereby deny the individual’s application.  
This decision is final.  The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Encl						     
						         
CF: 
(  ) DoD PDBR
(  ) DVA